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Batra M, Ikeri K, Blake M, Mantell G, Bhat R, Zayek M. Oral dextrose gel for hypoglycemia in a well-baby nursery: a baby-friendly initiative. J Perinatol 2024:10.1038/s41372-024-02114-y. [PMID: 39271918 DOI: 10.1038/s41372-024-02114-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 08/28/2024] [Accepted: 09/05/2024] [Indexed: 09/15/2024]
Abstract
OBJECTIVES To assess the impact of oral dextrose gel (ODG) treatment on NICU admission rates for hypoglycemic infants in a well-baby nursery. STUDY DESIGN We retrospectively compared newborn infants at risk for hypoglycemia born during the intervention period (n = 3775) with historical controls (n = 655). We also compared the rates of the primary outcome (NICU admission) and secondary outcomes (exclusive breastfeeding and hospital costs) between the two periods. RESULTS Following the implementation of ODG supplementation, the NICU admissions rates dropped from 4% to 2%, p < 0.05, for at-risk infants and from 15% to 7%, p < 0.05, for hypoglycemic infants in the baseline and intervention periods, respectively, with an adjusted OR (95% CI) of 0.39 (0.24-0.64), p < 0.001. Additionally, the ODG protocol sustained rates of exclusive breastfeeding in contrast to the institutional protocol. CONCLUSION The adoption of an ODG protocol fosters a more nurturing and baby-friendly environment through reduced NICU transfers, support for exclusive breastfeeding, and decreased hospital costs.
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Affiliation(s)
- Mansi Batra
- Department of Pediatrics, Division of Neonatology, University of South Alabama, Mobile, AL, USA
| | - Kelechi Ikeri
- Department of Pediatrics, Division of Neonatology, University of South Alabama, Mobile, AL, USA
| | - Michelle Blake
- Department of Nursing, USA Children's and Women's Hospital, Mobile, AL, USA
| | | | - Ramachandra Bhat
- Department of Neonatology, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi, India
| | - Michael Zayek
- Department of Pediatrics, Division of Neonatology, University of South Alabama, Mobile, AL, USA.
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2
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Wei X, Franke N, Alsweiler JM, Brown GTL, Gamble GD, McNeill A, Rogers J, Thompson B, Turuwhenua J, Wouldes TA, Harding JE, McKinlay CJD. Neonatal Hypoglycemia and Neurocognitive Function at School Age: A Prospective Cohort Study. J Pediatr 2024; 272:114119. [PMID: 38815750 DOI: 10.1016/j.jpeds.2024.114119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 04/22/2024] [Accepted: 05/22/2024] [Indexed: 06/01/2024]
Abstract
OBJECTIVE To determine the relationship between transient neonatal hypoglycemia in at-risk infants and neurocognitive function at 6-7 years of corrected age. STUDY DESIGN The pre-hPOD Study involved children born with at least 1 risk factor for neonatal hypoglycemia. Hypoglycemia was defined as ≥1 consecutive blood glucose concentrations <47 mg/dl (2.6 mmol/L), severe as <36 mg/dl (2.0 mmol/L), mild as 36 to <47 mg/dL (2.0 to <2.6 mmol/L), brief as 1-2 episodes, and recurrent as ≥3 episodes. At 6-7 years children were assessed for cognitive and motor function (NIH-Toolbox), learning, visual perception and behavior. The primary outcome was neurocognitive impairment, defined as >1 SD below the normative mean in ≥1 Toolbox tests. The 8 secondary outcomes covered children's cognitive, motor, language, emotional-behavioral, and visual perceptual development. Primary and secondary outcomes were compared between children who did and did not experience neonatal hypoglycemia, adjusting for potential confounding by gestation, birthweight, sex and receipt of prophylactic dextrose gel (pre-hPOD intervention). Secondary analysis included assessment by severity and frequency of hypoglycemia. RESULTS Of 392 eligible children, 315 (80%) were assessed at school age (primary outcome, n = 308); 47% experienced hypoglycemia. Neurocognitive impairment was similar between exposure groups (hypoglycemia 51% vs 50% no hypoglycemia; aRD -4%, 95% CI -15%, 7%). Children with severe or recurrent hypoglycemia had worse visual motion perception and increased risk of emotional-behavioral difficulty. CONCLUSION Exposure to neonatal hypoglycemia was not associated with risk of neurocognitive impairment at school-age in at-risk infants, but severe and recurrent episodes may have adverse impacts. TRIAL REGISTRATION Hypoglycemia Prevention in Newborns with Oral Dextrose: the Dosage Trial (pre-hPOD Study): ACTRN12613000322730.
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Affiliation(s)
- Xingyu Wei
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Nike Franke
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Jane M Alsweiler
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Gavin T L Brown
- Education and Social Work, University of Auckland, Auckland, New Zealand
| | - Gregory D Gamble
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Alicia McNeill
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Jenny Rogers
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Benjamin Thompson
- School of Optometry and Vision Science, University of Waterloo, Waterloo, ON, Canada; School of Optometry and Vision Science, University of Auckland, Auckland, New Zealand; Centre for Eye and Vision Research, Hong Kong, China
| | - Jason Turuwhenua
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Trecia A Wouldes
- Department of Psychological Medicine, University of Auckland, Auckland, New Zealand
| | - Jane E Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Christopher J D McKinlay
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand.
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Vaidyanathan L, Reid D, Yuan Y, Groves A. The impact of implementation of oral dextrose gel on the incidence of multiple hypoglycemia events in the well newborn nursery. J Perinatol 2024:10.1038/s41372-024-02032-z. [PMID: 38926525 DOI: 10.1038/s41372-024-02032-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 05/31/2024] [Accepted: 06/12/2024] [Indexed: 06/28/2024]
Abstract
OBJECTIVE Evaluate the impact of 40% oral dextrose gel (DG) for management of neonatal hypoglycemia (NH) on the incidence of multiple hypoglycemic events in the well-baby nursery. STUDY DESIGN A retrospective chart review of 738 at-risk infants in 2 cohorts before (Cohort 1) and after (Cohort 2) DG implementation. Primary outcome was the incidence of ≥2 hypoglycemic episodes. Secondary outcomes were number of lowest median glucose level, and incidence of NICU admission. RESULTS There were 384 and 354 at-risk newborns in Cohorts 1 & 2. The incidence of developing ≥2 hypoglycemia episodes significantly decreased following DG implementation [62(42.5%) vs 29(25.9%), p = 0.0058]. There were no differences in lowest glucose level [37 (14-45) vs 37 (10-45), p = 0.31], and NICU admission rate [31 (21.2%) vs 21 (18.8%), p = 0.62]. CONCLUSIONS Implementation of DG lowers the incidence of subsequent hypoglycemia episodes.
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Affiliation(s)
- Lakshmy Vaidyanathan
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin, Austin, TX, USA.
- Pediatrix, Sunrise, FL, USA.
| | | | - Yingchao Yuan
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Alan Groves
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
- Pediatrix, Sunrise, FL, USA
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Wei X, Franke N, Alsweiler JM, Brown GTL, Gamble GD, McNeill A, Rogers J, Thompson B, Turuwhenua J, Wouldes TA, Harding JE, McKinlay CJD. Dextrose gel prophylaxis for neonatal hypoglycaemia and neurocognitive function at early school age: a randomised dosage trial. Arch Dis Child Fetal Neonatal Ed 2024; 109:421-427. [PMID: 38307710 PMCID: PMC11186727 DOI: 10.1136/archdischild-2023-326452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 12/07/2023] [Indexed: 02/04/2024]
Abstract
OBJECTIVE To investigate the effect of different doses of prophylactic dextrose gel on neurocognitive function and health at 6-7 years. DESIGN Early school-age follow-up of the pre-hPOD (hypoglycaemia Prevention with Oral Dextrose) study. SETTING Schools and communities. PATIENTS Children born at ≥35 weeks with ≥1 risk factor for neonatal hypoglycaemia: maternal diabetes, small or large for gestational age, or late preterm. INTERVENTIONS Four interventions commencing at 1 hour of age: dextrose gel (40%) 200 mg/kg; 400 mg/kg; 200 mg/kg and 200 mg/kg repeated before three feeds (800 mg/kg); 400 mg/kg and 200 mg/kg before three feeds (1000 mg/kg); compared with equivolume placebo (combined for analysis). MAIN OUTCOMES MEASURES Toolbox cognitive and motor batteries, as well as tests of motion perception, numeracy and cardiometabolic health, were used. The primary outcome was neurocognitive impairment, defined as a standard score of more than 1 SD below the age-corrected mean on one or more Toolbox tests. FINDINGS Of 392 eligible children, 309 were assessed for the primary outcome. There were no significant differences in the rate of neurocognitive impairment between those randomised to placebo (56%) and dextrose gel (200 mg/kg 46%: adjusted risk difference (aRD)=-14%, 95% CI -35%, 7%; 400 mg/kg 48%: aRD=-7%, 95% CI -27%, 12%; 800 mg/kg 45%: aRD=-14%, 95% CI -36%, 9%; 1000 mg/kg 50%: aRD=-8%, 95% CI -29%, 13%). Children exposed to any dose of dextrose gel (combined), compared with placebo, had a lower risk of motor impairment (3% vs 14%, aRD=-11%, 95% CI -19%, -3%) and higher mean (SD) cognitive scores (106.0 (15.3) vs 101.1 (15.7), adjusted mean difference=5.4, 95% CI 1.8, 8.9). CONCLUSIONS Prophylactic neonatal dextrose gel did not alter neurocognitive impairment at early school age but may have motor and cognitive benefits. Further school-age follow-up studies are needed.
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Affiliation(s)
- Xingyu Wei
- Liggins Institute, The University of Auckland, Auckland, New Zealand, Auckland, New Zealand
| | - Nike Franke
- Liggins Institute, The University of Auckland, Auckland, New Zealand, Auckland, New Zealand
| | - Jane M Alsweiler
- Paediatrics: Child and Youth Health, The University of Auckland Faculty of Medical and Health Sciences, Auckland, New Zealand
| | - Gavin T L Brown
- Learning, Development and Professional Practice, The University of Auckland, Auckland, New Zealand
| | - Gregory D Gamble
- Liggins Institute, The University of Auckland, Auckland, New Zealand, Auckland, New Zealand
| | - Alicia McNeill
- Liggins Institute, The University of Auckland, Auckland, New Zealand, Auckland, New Zealand
| | - Jenny Rogers
- Liggins Institute, The University of Auckland, Auckland, New Zealand, Auckland, New Zealand
| | - Benjamin Thompson
- Optometry and Vision Science, University of Waterloo, Waterloo, Ontario, Canada
- Optometry and Vision Science, University of Auckland, Auckland, New Zealand
| | - Jason Turuwhenua
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Trecia A Wouldes
- Department of Psychological Medicine, The University of Auckland, Auckland, New Zealand
| | - Jane E Harding
- Liggins Institute, The University of Auckland, Auckland, New Zealand, Auckland, New Zealand
| | - Christopher J D McKinlay
- Paediatrics: Child and Youth Health, The University of Auckland Faculty of Medical and Health Sciences, Auckland, New Zealand
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Lord L, Rogers J, Gamble GD, Harding JE. Are toddlers with neurosensory impairment more difficult to follow up? A secondary analysis of the hPOD follow-up study. Arch Dis Child Fetal Neonatal Ed 2024:fetalneonatal-2023-326455. [PMID: 38604648 DOI: 10.1136/archdischild-2023-326455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 03/19/2024] [Indexed: 04/13/2024]
Abstract
OBJECTIVE To describe strategies used to maximise follow-up after a neonatal randomised trial, how these differed for families of different ethnicity, socioeconomic status and urban versus rural residence and investigate relationships between the difficulty of follow-up and rate of neurosensory impairment. METHOD hPOD was a multicentre randomised trial assessing oral dextrose gel prophylaxis for neonatal hypoglycaemia. Follow-up at 2 years was conducted from 2017 to 2021. We analysed all recorded contacts between the research team and participants' families. Neurosensory impairment was defined as blindness, deafness, cerebral palsy, developmental delay or executive function impairment. RESULTS Of 1321 eligible participants, 1197 were assessed (91%) and 236/1194 (19.8%) had neurosensory impairment. Participants received a median of five contacts from the research team (range 1-23). Those from more deprived areas and specific ethnicities received more contacts, particularly home tracking visits and home assessments. Impairment was more common among participants receiving more contacts (relative risk 1.81, 95% CI 1.34 to 2.44 for ≥7 contacts vs <7 contacts), and among those assessed after the intended age (76/318, 23.9% if >25 months vs 160/876, 18.3% if ≤25 months). CONCLUSIONS Varied contact strategies and long timeframes are required to achieve a high follow-up rate. Without these, the sociodemographics of children assessed would not have been representative of the entire cohort, and the rate of neurosensory impairment would have been underestimated. To maximise follow-up after randomised trials, substantial effort and resources are needed to ensure that data are useful for clinical decision-making.
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Affiliation(s)
- Libby Lord
- The University of Auckland Liggins Institute, Auckland, New Zealand
| | - Jenny Rogers
- The University of Auckland Liggins Institute, Auckland, New Zealand
| | - Greg D Gamble
- The University of Auckland Liggins Institute, Auckland, New Zealand
| | - Jane E Harding
- The University of Auckland Liggins Institute, Auckland, New Zealand
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Harding JE, Alsweiler JM, Edwards TE, McKinlay CJD. Neonatal hypoglycaemia. BMJ MEDICINE 2024; 3:e000544. [PMID: 38618170 PMCID: PMC11015200 DOI: 10.1136/bmjmed-2023-000544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 03/04/2024] [Indexed: 04/16/2024]
Abstract
Low blood concentrations of glucose (hypoglycaemia) soon after birth are common because of the delayed metabolic transition from maternal to endogenous neonatal sources of glucose. Because glucose is the main energy source for the brain, severe hypoglycaemia can cause neuroglycopenia (inadequate supply of glucose to the brain) and, if severe, permanent brain injury. Routine screening of infants at risk and treatment when hypoglycaemia is detected are therefore widely recommended. Robust evidence to support most aspects of management is lacking, however, including the appropriate threshold for diagnosis and optimal monitoring. Treatment is usually initially more feeding, with buccal dextrose gel, followed by intravenous dextrose. In infants at risk, developmental outcomes after mild hypoglycaemia seem to be worse than in those who do not develop hypoglycaemia, but the reasons for these observations are uncertain. Here, the current understanding of the pathophysiology of neonatal hypoglycaemia and recent evidence regarding its diagnosis, management, and outcomes are reviewed. Recommendations are made for further research priorities.
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Affiliation(s)
- Jane E Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Jane M Alsweiler
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
- Te Whatu Ora Health New Zealand, Te Toka Tumai, Auckland, New Zealand
| | - Taygen E Edwards
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Chris JD McKinlay
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
- Te Whatu Ora Health New Zealand, Counties Manukau, Auckland, New Zealand
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7
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De Rose DU, Perri A, Maggio L, Salvatori G, Dotta A, Vento G, Gallini F. Neonatal hypoglycemia and neurodevelopmental outcomes: Yesterday, today, tomorrow. Eur J Pediatr 2024; 183:1113-1119. [PMID: 38180635 DOI: 10.1007/s00431-023-05405-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 12/16/2023] [Accepted: 12/21/2023] [Indexed: 01/06/2024]
Abstract
Neonatal hypoglycemia is a major source of concern for pediatricians since it has commonly been related to poor neurodevelopmental outcomes. Diagnosis is challenging, considering the different operational thresholds provided by each guideline. Screening of infants at risk plays a crucial role, considering that most hypoglycemic infants show no clinical signs. New opportunities for prevention and treatment are provided by the use of oral dextrose gel. Continuous glucose monitoring systems could be a feasible tool in the next future. Furthermore, there is still limited evidence to underpin the current clinical practice of administering, in case of hypoglycemia, an intravenous "mini-bolus" of 10% dextrose before starting a continuous dextrose infusion. This brief review provides an overview of the latest advances in this field and neurodevelopmental outcomes according to different approaches. Conclusion: To adequately define if a more permissive approach is risk-free for neurodevelopmental outcomes, more research on continuous glucose monitoring and long-term follow-up is still needed. What is Known: • Neonatal hypoglycemia (NH) is a well-known cause of brain injury that could be prevented to avoid neurodevelopmental impairment. • Diagnosis is challenging, considering the different suggested operational thresholds for NH (<36, <40, <45, <47 or <50 mg/dl). What is New: • A 36 mg/dl threshold seems to be not associated with a worse psychomotor development at 18 months of life when compared to the "traditional" threshold (47 mg/dl). • Further studies on long-term neurodevelopmental outcomes are required before suggesting a more permissive management of NH.
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Affiliation(s)
| | - Alessandro Perri
- Neonatology Unit, Department of Woman and Child Health and Public Health - Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
| | - Luca Maggio
- Università Cattolica del Sacro Cuore, Rome, Italy
- Neonatology Unit, "San Camillo-Forlanini" Hospital, Rome, Italy
| | - Guglielmo Salvatori
- Neonatal Intensive Care Unit, "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
| | - Andrea Dotta
- Neonatal Intensive Care Unit, "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
| | - Giovanni Vento
- Neonatology Unit, Department of Woman and Child Health and Public Health - Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesca Gallini
- Università Cattolica del Sacro Cuore, Rome, Italy
- Neonatal Intensive Care Unit, "Gemelli Isola" Hospital, Rome, Italy
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Wang MQ, Zheng YN, Zhuang Y. Oral glucose gel in the prevention of neonatal hypoglycemia: A systematic review and meta-analysis. Medicine (Baltimore) 2023; 102:e36137. [PMID: 38050311 PMCID: PMC10695523 DOI: 10.1097/md.0000000000036137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 10/25/2023] [Indexed: 12/06/2023] Open
Abstract
BACKGROUND Neonatal hypoglycemia (NH) is the most prevalent metabolic disorder in neonates and glucose gel in oral solution is a relatively new treatment option for NH. We aimed to determine whether oral glucose gel can prevent NH. METHODS We conducted an open literature search using PubMed, Embase, Cochrane Library, and Web of Science. We used relative risk as the statistical data, expressed each outcome effect as a 95% confidence interval, and conducted a heterogeneity test. If heterogeneity statistics indicated that I2 was ≥ 50%, the random effects model analysis was used; otherwise, the fixed effects model analysis was conducted, and sensitivity analyses were conducted for all outcomes. RESULTS In this review, we included a total of 10 studies involving 4801 neonates. Meta-analysis revealed that there were no significant differences between the preventive oral glucose gel group and the control group in terms of blood glucose concentration, glucose concentration 30 minutes after the first breastfeeding, length of stay, Bayley-III composite score, subsequent need for intravenous injection of glucose, 24-hour glucose > 50 mg/dL, separation from mother for treatment of hypoglycemia/admitted to neonatal intensive care unit for hypoglycemia, normoglycemia after 1 to 2 treatments, or normoglycemia after more than 2 treatments, breastfeeding at discharge, delayed feeding, neurosensory impairment, parental satisfaction, developmental delay, and seizure. The subsequent intake was significantly lower in the glucose gel group compared to the control group. INTERPRETATION The use of oral glucose gel as a preventative measure may not reduce the incidence of NH. In order to assess the efficacy of glucose gel in preventing NH, a more high-quality, large-sample, and rigorously designed randomized controlled trial is required.
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Affiliation(s)
- Meng-Qin Wang
- Department of Obstetrics, Nanjing Drum Tower Hospital, Nanjing, China
| | - Ya-Ning Zheng
- Department of Gynecology otolaryngology, Nanjing Drum Tower Hospital, Nanjing, China
| | - Ying Zhuang
- Department of Obstetrics, Nanjing Drum Tower Hospital, Nanjing, China
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King G, Tabery K, Hall M, Kelleher J. Delivery room glucose to reduce the risk of admission hypoglycemia in preterm infants: a systematic literature review. J Matern Fetal Neonatal Med 2023; 36:2183466. [PMID: 36863705 DOI: 10.1080/14767058.2023.2183466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
AIMS In order to mitigate early hypoglycemia in preterm infants, some clinicians have recently explored interventions such as delivery room commencement of dextrose infusions or delivery room administration of buccal dextrose gel. This review aimed to systematically investigate the literature regarding the provision of delivery room (prior to admission) parenteral glucose as a method to reduce the risk of initial hypoglycemia (measured at the time of NICU admission blood testing) in preterm infants. MATERIALS AND METHODS Using PRISMA guidelines a literature search (May 2022) was conducted using PubMed, Embase, Scopus, Cochrane Library, OpenGrey, and Prospero databases. The clinicaltrials.gov database was searched for possible completed/ongoing clinical trials. Studies that included moderate preterm (≤33+6 weeks) or younger birth gestations or very low birth weight (or smaller) infants, and that administered parenteral glucose in the delivery room were included. The literature was appraised via data extraction, narrative synthesis, and critical review of the study data. RESULTS A total of five studies (published 2014-2022) were eligible for inclusion (three before-after "quasi-experimental" studies, one retrospective cohort study, and one case-control study). Most included studies used intravenous dextrose as the intervention. Individual study effects (odds ratios) favored the intervention in all included studies. It was felt that the low number of studies, the variability in study design, and the nonadjustment for confounding co-interventions (co-exposures) precluded a meta-analysis. Quality assessment of the studies revealed a spectrum of bias from low to high risk, however, most studies had moderate to high risk of bias, and their direction of bias favored the intervention. CONCLUSIONS This extensive search and systematic appraisal of the literature indicates that there exists few studies (these are low grade and at moderate to high risk of bias) for the interventions of either intravenous or buccal dextrose given in the delivery room. It is not clear if these interventions impact on rates of early (NICU admission) hypoglycemia in these preterm infants. Obtaining intravenous access in the delivery room is not guaranteed and can be difficult in these small infants. Future research should consider various routes for commencing delivery room glucose in these preterm infants and should take the form of randomized controlled trials.
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Affiliation(s)
- Graham King
- Trinity College Institute of Neuroscience, The University of Dublin Trinity College, Dublin, Ireland.,Department of Neonatology, Coombe Women and Infants University Hospital, Dublin, Ireland
| | - Krystof Tabery
- Department of Neonatology, Coombe Women and Infants University Hospital, Dublin, Ireland
| | - Michael Hall
- University Hospital Southampton (Visiting Professor in Neonatology), University of Southampton, Southampton, United Kingdom
| | - John Kelleher
- Department of Neonatology, Coombe Women and Infants University Hospital, Dublin, Ireland.,Paediatrics, School of Medicine, The University of Dublin Trinity College, Dublin, Ireland
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10
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Roberts L, Lin L, Alsweiler J, Edwards T, Liu G, Harding JE. Oral dextrose gel to prevent hypoglycaemia in at-risk neonates. Cochrane Database Syst Rev 2023; 11:CD012152. [PMID: 38014716 PMCID: PMC10683021 DOI: 10.1002/14651858.cd012152.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
BACKGROUND Neonatal hypoglycaemia is a common condition that can be associated with brain injury. Current practice usually includes early identification of at-risk infants (e.g. infants of diabetic mothers; preterm, small- or large-for-gestational-age infants), and prophylactic measures are advised. However, these measures often involve use of formula milk or admission to the neonatal unit. Dextrose gel is non-invasive, inexpensive and effective for treatment of neonatal hypoglycaemia. Prophylactic dextrose gel can reduce the incidence of neonatal hypoglycaemia, thus potentially reducing separation of mother and baby and supporting breastfeeding, as well as preventing brain injury. This is an update of a previous Cochrane Review published in 2021. OBJECTIVES To assess the effectiveness and safety of oral dextrose gel in preventing hypoglycaemia before first hospital discharge and reducing long-term neurodevelopmental impairment in newborn infants at risk of hypoglycaemia. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and Epistemonikos in April 2023. We also searched clinical trials databases and the reference lists of retrieved articles. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs comparing oral dextrose gel versus placebo, no intervention, or other therapies for the prevention of neonatal hypoglycaemia. We included newborn infants at risk of hypoglycaemia, including infants of mothers with diabetes (all types), high or low birthweight, and born preterm (< 37 weeks), age from birth to 24 hours, who had not yet been diagnosed with hypoglycaemia. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed the risk of bias. We contacted investigators to obtain additional information. We used fixed-effect meta-analyses. We used the GRADE approach to assess the certainty of evidence. MAIN RESULTS We included two studies conducted in high-income countries comparing oral dextrose gel versus placebo in 2548 infants at risk of neonatal hypoglycaemia. Both of these studies were included in the previous version of this review, but new follow-up data were available for both. We judged these two studies to be at low risk of bias in 13/14 domains, and that the evidence for most outcomes was of moderate certainty. Meta-analysis of the two studies showed that oral dextrose gel reduces the risk of hypoglycaemia (risk ratio (RR) 0.87, 95% confidence interval (CI) 0.79 to 0.95; risk difference (RD) -0.06, 95% CI -0.10 to -0.02; 2548 infants; high-certainty evidence). Evidence from two studies showed that there may be little to no difference in the risk of major neurological disability at two years of age after oral dextrose gel (RR 1.00, 95% CI 0.59 to 1.68; 1554 children; low-certainty evidence). Meta-analysis of the two studies showed that oral dextrose gel probably reduces the risk of receipt of treatment for hypoglycaemia during initial hospital stay (RR 0.89, 95% CI 0.79 to 1.00; 2548 infants; moderate-certainty evidence) but probably makes little or no difference to the risk of receipt of intravenous treatment for hypoglycaemia (RR 1.01, 0.68 to 1.49; 2548 infants; moderate-certainty evidence). Oral dextrose gel may have little or no effect on the risk of separation from the mother for treatment of hypoglycaemia (RR 1.12, 95% CI 0.81 to 1.55; two studies, 2548 infants; low-certainty evidence). There is probably little or no difference in the risk of adverse effects in infants who receive oral dextrose gel compared to placebo gel (RR 1.22, 95% CI 0.64 to 2.33; two studies, 2510 infants; moderate-certainty evidence), but there are no studies comparing oral dextrose with other comparators such as no intervention or other therapies. No data were available on exclusive breastfeeding after discharge. AUTHORS' CONCLUSIONS Prophylactic oral dextrose gel reduces the risk of neonatal hypoglycaemia in at-risk infants and probably reduces the risk of treatment for hypoglycaemia without adverse effects. It may make little to no difference to the risk of major neurological disability at two years, but the confidence intervals include the possibility of substantial benefit or harm. Evidence at six to seven years is limited to a single small study. In view of its limited short-term benefits, prophylactic oral dextrose gel should not be incorporated into routine practice until additional information is available about the balance of risks and harms for later neurological disability. Additional large follow-up studies at two years of age or older are required. Future research should also be undertaken in other high-income countries, low- and middle-income countries, preterm infants, using other dextrose gel preparations, and using comparators other than placebo gel. There are three studies awaiting classification and one ongoing study which may alter the conclusions of the review when published.
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Affiliation(s)
- Lily Roberts
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Luling Lin
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Jane Alsweiler
- Neonatal Intensive Care Unit, Auckland Hospital, Auckland, New Zealand
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Taygen Edwards
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Gordon Liu
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Jane E Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand
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11
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O'Brien M, Gilchrist C, Sadler L, Hegarty JE, Alsweiler JM. Infants Eligible for Neonatal Hypoglycemia Screening: A Systematic Review. JAMA Pediatr 2023; 177:1187-1196. [PMID: 37782488 PMCID: PMC10546298 DOI: 10.1001/jamapediatrics.2023.3957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 08/02/2023] [Indexed: 10/03/2023]
Abstract
Importance Neonatal hypoglycemia is common, occurring in up to 50% of infants at risk for hypoglycemia (infant of diabetic mother [IDM], small for gestational age [SGA], large for gestational age [LGA], and preterm) and is associated with long-term neurodevelopmental impairment. Guidelines recommend screening infants at risk of hypoglycemia. The proportion of infants who require screening for neonatal hypoglycemia is unknown. Objective To determine the proportion of infants eligible for neonatal hypoglycemia screening using criteria from the highest-scoring critically appraised clinical guideline. Design, Setting, and Participants This systematic review of the literature was conducted to identify clinical practice guidelines for neonatal hypoglycemia and took place at a tertiary maternity hospital in Auckland, New Zealand. Eligible guidelines were critically appraised using the Appraisal of Guidelines for Research and Evaluation II tool. Using screening criteria extracted from the highest-scoring guideline, the proportion of infants eligible for neonatal hypoglycemia screening was determined in a retrospective observational cohort study of infants born January 1, 2004, to December 31, 2018. Data were analyzed by logistic regression. Infant participants were included if gestational age was 35 weeks or more, birth weight was 2000 g or more, and they were not admitted to a neonatal intensive care unit less than 1 hour after birth. The data were analyzed from November 2022 through February 2023. A total of 101 372 infants met the inclusion criteria. Exposure Risk factors for neonatal hypoglycemia. Main Outcome Proportion of infants eligible for neonatal hypoglycemia screening. Results The study team screened 2366 abstracts and 18 guidelines met inclusion criteria for appraisal. There was variability in the assessed quality of guidelines and a lack of consensus between screening criteria. The highest-scoring guideline defined screening criteria as: IDM, preterm (less than 37 weeks' gestation), SGA (less than 10th percentile), birth weight of less than 2500 g or more than 4500 g, LGA (more than 90th percentile), or gestational age more than 42 weeks. A total of 101 372 infants met criteria for inclusion in the cohort study; median (IQR) gestational age was 39 (38-40) weeks and 51% were male. The overall proportion of infants eligible for screening was 26.3%. There was an increase in the proportion of eligible infants from 25.6% to 28.5% over 15 years, which was not statistically significant after adjustment for maternal age, body mass index, ethnicity, and multiple pregnancy (odds ratio, 0.99; 95% CI, 0.93-1.03; change in proportion per year). Conclusion A systematic review found that practice guidelines providing recommendations for clinical care of neonatal hypoglycemia were of variable quality with is a lack of consensus regarding definitions for infants at risk for hypoglycemia. In the cohort study, one-quarter of infants were eligible for hypoglycemia screening. Further research is required to identify which infants may benefit from neonatal hypoglycemia screening.
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Affiliation(s)
- Michelle O'Brien
- Department of Paediatrics, Child and Youth Health, Waipapa Taumata Rau - The University of Auckland, Auckland, New Zealand
- Newborn Services, Te Whatu Ora - Health New Zealand, Te Toka Tumai, Auckland, New Zealand
| | - Catherine Gilchrist
- Department of Paediatrics, Child and Youth Health, Waipapa Taumata Rau - The University of Auckland, Auckland, New Zealand
| | - Lynn Sadler
- Obstetrics and Gynaecology, Te Whatu Ora - Health New Zealand, Te Toka Tumai Auckland, New Zealand
- Women's Health, Te Whatu Ora - Health New Zealand, Te Toka Tumai, Auckland, New Zealand
| | - Joanne E Hegarty
- Newborn Services, Te Whatu Ora - Health New Zealand, Te Toka Tumai, Auckland, New Zealand
| | - Jane M Alsweiler
- Department of Paediatrics, Child and Youth Health, Waipapa Taumata Rau - The University of Auckland, Auckland, New Zealand
- Newborn Services, Te Whatu Ora - Health New Zealand, Te Toka Tumai, Auckland, New Zealand
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12
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Hulse WN, Schulte K, Eickelkamp-Marron V, Redder H, Davidson JM, Chan B, Torr C, DuPont TL, Grubb PH. A quality improvement initiative for neonatal hypoglycemia screening and management in a level III neonatal intensive care unit. J Perinatol 2023; 43:1321-1329. [PMID: 37532760 DOI: 10.1038/s41372-023-01740-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 07/07/2023] [Accepted: 07/24/2023] [Indexed: 08/04/2023]
Abstract
OBJECTIVE To bring screening and management of neonatal hypoglycemia in alignment with the 2011 AAP hypoglycemia clinical report METHODS: A multidisciplinary team developed a quality improvement initiative for neonatal hypoglycemia in neonates ≥35 weeks gestational age in a Level III neonatal intensive care unit between July 2020 and December 2021. A key driver diagram identified interventions for plan-do-study-act testing with corresponding measures to implement a hypoglycemia management protocol and improve adherence to AAP guidelines. RESULTS Time to first blood glucose measurement increased from 49.8 to 122.7 min of life and time to first enteral feed decreased from 14.2 to 3.6 h of life. Neonates receiving intravenous dextrose decreased from 97.1 to 24.7% and discharge rates as a mother-neonate dyad increased from 35 to 62.4%. CONCLUSIONS Adherence to the AAP guidelines improved during testing and implementation of a hypoglycemia protocol and was associated with an increased mother-neonate dyad discharge rate.
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Affiliation(s)
- Whitley N Hulse
- Division of Neonatology, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
- Division of Neonatology, Department of Pediatrics, University of Utah Health, Salt Lake City, UT, USA.
| | | | - Victoria Eickelkamp-Marron
- Division of Neonatology, Department of Pediatrics, University of Utah Health, Salt Lake City, UT, USA
- University of Utah Hospital, Salt Lake City, UT, USA
| | - Hannah Redder
- University of Utah Hospital, Salt Lake City, UT, USA
| | - Jessica M Davidson
- Division of Neonatology, Department of Pediatrics, University of Utah Health, Salt Lake City, UT, USA
| | - Belinda Chan
- Division of Neonatology, Department of Pediatrics, University of Utah Health, Salt Lake City, UT, USA
| | - Carrie Torr
- Division of Neonatology, Department of Pediatrics, University of Utah Health, Salt Lake City, UT, USA
| | - Tara L DuPont
- Division of Neonatology, Department of Pediatrics, University of Utah Health, Salt Lake City, UT, USA
| | - Peter H Grubb
- Division of Neonatology, Department of Pediatrics, University of Utah Health, Salt Lake City, UT, USA
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13
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Blanco CL, Smith V, Ramel SE, Martin CR. Dilemmas in parenteral glucose delivery and approach to glucose monitoring and interpretation in the neonate. J Perinatol 2023; 43:1200-1205. [PMID: 36964206 DOI: 10.1038/s41372-023-01640-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 12/16/2022] [Accepted: 02/23/2023] [Indexed: 03/26/2023]
Abstract
Glucose control continues to be challenging for intensivists, in particular in high-risk neonates. Many factors play a role in glucose regulation including intrinsic and extrinsic factors. Optimal targets for euglycemia are debatable with uncertain short and long-term effects. Glucose measurement technology has continued to advance over the past decade; unfortunately, the availability of these advanced devices outside of research continues to be problematic. Treatment approaches should be individualized depending on etiology, symptoms, and neonatal conditions. Glucose infusions should be titrated based upon variations in organ glucose uptake, co-morbidities and postnatal development. In this article we summarize the most common dilemmas encountered in the NICU: ranges for euglycemia, physiological differences, approach for glucose measurements, monitoring and best strategies to control parenteral glucose delivery.
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Affiliation(s)
- Cynthia L Blanco
- Department of Pediatrics, University of Texas Health Science Center San Antonio, San Antonio, TX, USA.
| | - Victor Smith
- Department of Pediatrics, University of Texas Health Science Center San Antonio, San Antonio, TX, USA
| | - Sara E Ramel
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - Camilia R Martin
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
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14
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McAllister J, Wexelblatt S, Ward L. Controversies and Conundrums in Newborn Feeding. Clin Perinatol 2023; 50:729-742. [PMID: 37536775 DOI: 10.1016/j.clp.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Breastfeeding is the biologic norm for newborn feeding, and exclusive breastfeeding for the first 6 months of life is universally endorsed by leading global and national organizations. Despite these recommendations, many people do not meet their breastfeeding goals and controversies surrounding breastfeeding problems exist. Medical issues can present challenges for the clinician and parents to successfully meet desired feeding outcomes. There are studies evaluating these common controversies and medical conundrums, and clinicians should provide evidence-based recommendations when counseling families about newborn feeding.
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Affiliation(s)
- Jennifer McAllister
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center Perinatal Institute, 3333 Burnet Avenue, ML 7009, Cincinnati, OH 45229, USA.
| | - Scott Wexelblatt
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center Perinatal Institute, 3333 Burnet Avenue, ML 7009, Cincinnati, OH 45229, USA
| | - Laura Ward
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center Perinatal Institute, 3333 Burnet Avenue, ML 7009, Cincinnati, OH 45229, USA
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15
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Wu T, Huang YY, Song W, Redding SR, Huang WP, Ouyang YQ. Development of a prediction model for neonatal hypoglycemia risk factors: a retrospective study. Front Endocrinol (Lausanne) 2023; 14:1199628. [PMID: 37529595 PMCID: PMC10389046 DOI: 10.3389/fendo.2023.1199628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 06/19/2023] [Indexed: 08/03/2023] Open
Abstract
Background It's challenging for healthcare workers to detect neonatal hypoglycemia due to its rapid progression and lack of aura symptoms. This may lead to brain function impairment for the newborn, placing a significant care burden on the family and creating an economic burden for society. Tools for early diagnosis of neonatal hypoglycemia are lacking. This study aimed to identify newborns at high risk of developing neonatal hypoglycemia early by developing a risk prediction model. Methods Using a retrospective design, pairs (470) of women and their newborns in a tertiary hospital from December 2021 to September 2022 were included in this study. Socio-demographic data and clinical data of mothers and newborns were collected. Univariate and multivariate logistic regression were used to screen optimized factors. A neonatal hypoglycemia risk nomogram was constructed using R software, and the calibration curve and receiver operator characteristic curve (ROC) was utilized to evaluate model performance. Results Factors integrated into the prediction risk nomogram were maternal age (odds ratio [OR] =1.10, 95% CI: 1.04, 1.17), fasting period (OR=1.07, 95% CI: 1.03, 1.12), ritodrine use (OR=2.00, 95% CI: 1.05, 3.88), gestational diabetes mellitus (OR=2.13, 95% CI: 1.30, 3.50), gestational week (OR=0.80, 95% CI: 0.66, 0.96), fetal distress (OR=1.76, 95% CI: 1.11, 2.79) and neonatal body mass index (OR=1.50, 95% CI: 1.24, 1.84). The area under the curve (AUC) was 0.79 (95% confidence interval [CI]: 0.75, 0.82), specificity was 0.82, and sensitivity was 0.62. Conclusion The prediction model of this study demonstrated good predictive performance. The development of the model identifies advancing maternal age, an extended fasting period before delivery, ritodrine use, gestational diabetes mellitus diagnosis, fetal distress diagnosis and an increase in neonatal body mass index increase the probability of developing neonatal hypoglycemia, while an extended gestational week reduces the probability of developing neonatal hypoglycemia.
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Affiliation(s)
- Tian Wu
- School of Nursing, Wuhan University, Wuhan, Hubei, China
- Department of Obstetrics, Wuhan Central Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yi-Yan Huang
- School of Nursing, Wuhan University, Wuhan, Hubei, China
- Department of Nursing, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wei Song
- Department of Obstetrics, Wuhan Central Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | | | - Wei-Peng Huang
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
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16
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King B, Patel RM. Using Quality Improvement to Improve Value and Reduce Waste. Clin Perinatol 2023; 50:489-506. [PMID: 37201993 DOI: 10.1016/j.clp.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Value is defined as health outcomes achieved per dollar spent. Addressing value in quality improvement (QI) efforts can help optimize patient outcomes while reducing unnecessary spending. In this article, we discuss how QI focused on reducing morbidities frequently reduces costs, and how proper cost accounting can help demonstrate improvements in value. We provide examples of high-yield opportunities for value improvement in neonatology and review the literature associated with these topics. Opportunities include reducing neonatal intensive care admissions for low-acuity infants, sepsis evaluations in low-risk infants, unnecessary total parental nutrition use, and utilization of laboratory and imaging.
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Affiliation(s)
- Brian King
- Department of Pediatrics, University of Pittsburg School of Medicine.
| | - Ravi M Patel
- Emory University School of Medicine and Children's Healthcare of Atlanta, 2015 Uppergate Drive, NE, Atlanta, GA 30322, USA
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17
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Irvine LM, Harris DL. What are the barriers preventing the screening and management of neonatal hypoglycaemia in low-resource settings, and how can they be overcome? Matern Health Neonatol Perinatol 2023; 9:8. [PMID: 37259172 DOI: 10.1186/s40748-023-00162-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 05/23/2023] [Indexed: 06/02/2023] Open
Abstract
Over 25 years ago, the World Health Organization (WHO) acknowledged the importance of effective prevention, detection and treatment of neonatal hypoglycaemia, and declared it to be a global priority. Neonatal hypoglycaemia is common, linked to poor neurosensory outcomes and, if untreated, can cause seizures and death. Neonatal mortality in low and lower-middle income countries constitutes an estimated 89% of overall neonatal deaths. Factors contributing to high mortality rates include malnutrition, infectious diseases, poor maternal wellbeing and resource constraints on both equipment and staff, leading to delayed diagnosis and treatment. The incidence of neonatal hypoglycaemia in low and lower-middle income countries remains unclear, as data are not collected.Data from high-resource settings shows that half of all at-risk babies will develop hypoglycaemia, using accepted clinical thresholds for treatment. Most at-risk babies are screened and treated, with treatment aiming to increase blood glucose concentration and, therefore, available cerebral fuel. The introduction of buccal dextrose gel as a first-line treatment for neonatal hypoglycaemia has changed the care of millions of babies and families in high-resource settings. Dextrose gel has now also been shown to prevent neonatal hypoglycaemia.In low and lower-middle income countries, there are considerable barriers to resources which prevent access to reliable blood glucose screening, diagnosis, and treatment, leading to inequitable health outcomes when compared with developed countries. Babies born in low-resource settings do not have access to basic health care and are more likely to suffer from unrecognised neonatal hypoglycaemia, which contributes to the burden of neurosensory delay and death.
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Affiliation(s)
- Lauren M Irvine
- School of Nursing, Midwifery, and Health Practice, Faculty of Health, Victoria University of Wellington - Te Herenga Waka, Deborah Harris Level 7, Clinical Services Block, Wellington Regional Hospital, Newtown, Wellington, 6021, New Zealand
| | - Deborah L Harris
- School of Nursing, Midwifery, and Health Practice, Faculty of Health, Victoria University of Wellington - Te Herenga Waka, Deborah Harris Level 7, Clinical Services Block, Wellington Regional Hospital, Newtown, Wellington, 6021, New Zealand.
- Liggins Institute, University of Auckland, Auckland, New Zealand.
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18
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Parappil H, Gaffari M, Ahmed J, Skaria S, Rijims M, Chandra P, Babu KTS. Oral Dextrose gel use in asymptomatic hypoglycemic newborns decreases NICU admissions and parenteral dextrose therapy: A retrospective study. J Neonatal Perinatal Med 2023; 16:111-117. [PMID: 36872799 DOI: 10.3233/npm-221170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
BACKGROUND Neonatal hypoglycemia is one of the most common causes of admission to neonatal intensive care unit requiring intravenous dextrose therapy. Administration of IV dextrose and transfer to the NICU may interfere with parent-infant bonding, breastfeeding, and has financial implications. OBJECTIVE Retrospective study to evaluate the effect of dextrose gel supplementation for asymptomatic hypoglycemia in reducing NICU admissions and intravenous dextrose therapy. METHOD A retrospective study conducted for eight months each before and after introduction of dextrose gel in the management of asymptomatic neonatal hypoglycemia. Asymptomatic hypoglycemic infants were given only feeds in pre dextrose gel period and dextrose gel along with feeds in the dextrose gel period. Rates of admission to NICU and the need of IV dextrose therapy were evaluated. RESULTS High risk characteristics (Prematurity, Large for Gestational Age, small for Gestational Age, Infants of diabetic mother etc.) were equally distributed among both the cohorts. Primary outcome results showed significant reduction in NICU admissions from 396/1801(22%) to 329/1783 (18.5%) (odds ratio, 95% CI 1.24(1.05-1.46, p 0.008). There was significant reduction in IV dextrose therapy requirement from 277/1405 (15.4%) to 182/1454 (10.2%) (odds ratio, 95% CI 1.59(1.31- 1.95, p < 0.001).Babies discharged on predominant breast feeding showed significant improvement from 237/396(59.8%) in the pre dextrose gel period to 240/329 (72.9%) (odds ratio, 95% CI 0.82(0.73-0.90, p < 0.001) in dextrose gel period. CONCLUSIONS Dextrose gel supplementation with feeds reduced NICU admissions, the need for parenteral dextrose therapy, avoided maternal separation and promoted breastfeeding.
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Affiliation(s)
- H Parappil
- Department of Neonatology, Women wellness and Research Centre, Hamad Medical Corporation, Doha, State of Qatar.,Department of Pediatrics, Weill Cornell Medical College, Doha, State of Qatar
| | - M Gaffari
- Department of Neonatology, Women wellness and Research Centre, Hamad Medical Corporation, Doha, State of Qatar
| | - J Ahmed
- Department of Neonatology, Women wellness and Research Centre, Hamad Medical Corporation, Doha, State of Qatar
| | - S Skaria
- Department of Nursing, Women wellness and Research Centre, Hamad Medical Corporation, Doha, State of Qatar
| | - M Rijims
- Department of Pharmacy Women wellness and Research Centre, Hamad Medical Corporation, Doha, State of Qatar
| | - P Chandra
- Department of Statistics, Hamad Medical Corporation Doha, State of Qatar
| | - K T S Babu
- Department of Neonatology, Women wellness and Research Centre, Hamad Medical Corporation, Doha, State of Qatar
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Caffarelli C, Santamaria F, Piro E, Basilicata S, Delle Cave V, Cipullo M, Bernasconi S, Corsello G. New insights in pediatrics in 2021: choices in allergy and immunology, critical care, endocrinology, gastroenterology, genetics, haematology, infectious diseases, neonatology, neurology, nutrition, palliative care, respiratory tract illnesses and telemedicine. Ital J Pediatr 2022; 48:189. [PMID: 36435791 PMCID: PMC9701393 DOI: 10.1186/s13052-022-01374-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 10/25/2022] [Indexed: 11/28/2022] Open
Abstract
In this review, we report the developments across pediatric subspecialties that have been published in the Italian Journal of Pediatrics in 2021. We highlight advances in allergy and immunology, critical care, endocrinology, gastroenterology, genetics, hematology, infectious diseases, neonatology, neurology, nutrition, palliative care, respiratory tract illnesses and telemedicine.
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Affiliation(s)
- Carlo Caffarelli
- Department of Medicine and Surgery, Clinica Pediatrica, Azienda Ospedaliera-Universitaria, University of Parma, Via Gramsci 14, Parma, Italy.
| | - Francesca Santamaria
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Ettore Piro
- Department of Sciences for Health Promotion and Mother and Child Care G. D'Alessandro, University of Palermo, Palermo, Italy
| | - Simona Basilicata
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Valeria Delle Cave
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Marilena Cipullo
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | | | - Giovanni Corsello
- Department of Sciences for Health Promotion and Mother and Child Care G. D'Alessandro, University of Palermo, Palermo, Italy
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20
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Edwards T, Alsweiler JM, Gamble GD, Griffith R, Lin L, McKinlay CJD, Rogers JA, Thompson B, Wouldes TA, Harding JE. Neurocognitive Outcomes at Age 2 Years After Neonatal Hypoglycemia in a Cohort of Participants From the hPOD Randomized Trial. JAMA Netw Open 2022; 5:e2235989. [PMID: 36219444 PMCID: PMC9554702 DOI: 10.1001/jamanetworkopen.2022.35989] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Neonatal hypoglycemia is common, but its association with later neurodevelopment is uncertain. OBJECTIVE To examine associations between neonatal hypoglycemia and neurocognitive outcomes at corrected age 2 years. DESIGN, SETTING, AND PARTICIPANTS Exploratory cohort analysis of the Hypoglycaemia Prevention With Oral Dextrose (hPOD) randomized clinical trial was conducted. The trial recruited participants from January 9, 2015, to May 5, 2019, with follow-up between January 26, 2017, and July 31, 2021. Infants were recruited from 9 maternity hospitals in New Zealand and assessed at home or in a research clinic. Children born late preterm and at term at risk of neonatal hypoglycemia but without evidence of acute or imminent illness in the first hour after birth were screened and treated to maintain blood glucose concentrations greater than or equal to 47 mg/dL. EXPOSURES Hypoglycemia was defined as any blood glucose concentration less than 47 mg/dL, recurrent as 3 or more episodes, and severe as less than 36 mg/dL. MAIN OUTCOMES AND MEASURES Neurologic examination and tests of development (Bayley III) and executive function. The primary outcome was neurosensory impairment (any of the following: blindness, deafness, cerebral palsy, developmental delay, or executive function total score worse than 1.5 SD below the mean). RESULTS A total of 1197 of 1321 (91%) eligible children were assessed at a mean of corrected age 24 months; 616 (52%) were male. Compared with the normoglycemia group, children who experienced hypoglycemia were more likely to have neurosensory impairment (111 [23%] vs 125 [18%]; adjusted risk ratio [aRR], 1.28; 95% CI, 1.01-1.60), particularly if they experienced severe episodes (30 [28%] vs 125 [18%]; aRR, 1.68; 95% CI, 1.20-2.36), but not recurrent episodes (12 [19%] vs 125 [18%]; aRR, 1.06; 95% CI, 0.63-1.80). The risk of cognitive, language, or motor delay was similar between groups, but children who experienced hypoglycemia had lower Bayley-III composite cognitive (adjusted mean difference [aMD], -1.48; 95% CI, -2.79 to -0.18) and motor scores (aMD, -2.05; 95% CI, -3.30 to -0.79). CONCLUSIONS AND RELEVANCE In children born at risk of hypoglycemia but otherwise well, those who experienced neonatal hypoglycemia were more likely to have neurosensory impairment at corrected age 2 years, with higher risks after severe episodes. Further research is required to determine causality.
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Affiliation(s)
- Taygen Edwards
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Jane M. Alsweiler
- Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand
- Newborn Services, Auckland City Hospital, Auckland, New Zealand
| | - Greg D. Gamble
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Rebecca Griffith
- Kidz First Neonatal Care, Counties Manukau Health, Auckland, New Zealand
| | - Luling Lin
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Christopher J. D. McKinlay
- Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand
- Kidz First Neonatal Care, Counties Manukau Health, Auckland, New Zealand
| | - Jenny A. Rogers
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Benjamin Thompson
- School of Optometry and Vision Science, Waterloo, Canada
- Center for Eye and Vision Research, Hong Kong
| | - Trecia A. Wouldes
- Department of Psychological Medicine, The University of Auckland, Auckland, New Zealand
| | - Jane E. Harding
- Liggins Institute, The University of Auckland, Auckland, New Zealand
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21
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St Clair SL, Harding JE, O'Sullivan JM, Gamble GD, Alsweiler JM, Vatanen T. Effect of prophylactic dextrose gel on the neonatal gut microbiome. Arch Dis Child Fetal Neonatal Ed 2022; 107:501-507. [PMID: 34857640 PMCID: PMC9160211 DOI: 10.1136/archdischild-2021-322757] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 11/05/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To determine the effect of prophylactic dextrose gel on the infant gut microbiome. DESIGN Observational cohort study nested in a randomised trial. SETTING Three maternity hospitals in New Zealand. PATIENTS Infants at risk of neonatal hypoglycaemia whose parents consented to participation in the hypoglycaemia Prevention in newborns with Oral Dextrose trial (hPOD). Infants were randomised to receive prophylactic dextrose gel or placebo gel, or were not randomised and received no gel (controls). Stool samples were collected on days 1, 7 and 28. MAIN OUTCOME MEASURES The primary outcome was microbiome beta-diversity at 4 weeks. Secondary outcomes were beta-diversity, alpha-diversity, bacterial DNA concentration, microbial community stability and relative abundance of individual bacterial taxa at each time point. RESULTS We analysed 434 stool samples from 165 infants using 16S rRNA gene amplicon sequencing. There were no differences between groups in beta-diversity at 4 weeks (p=0.49). There were also no differences between groups in any other microbiome measures including beta-diversity (p=0.53 at day 7), alpha-diversity (p=0.46 for day 7 and week 4), bacterial DNA concentration (p=0.91), microbial community stability (p=0.52) and microbial relative abundance at genus level. There was no evidence that exposure to any dextrose gel (prophylaxis or treatment) had any effect on the microbiome. Mode of birth, type of milk fed, hospital of birth and ethnicity were all associated with differences in the neonatal microbiome. CONCLUSIONS Clinicians and consumers can be reassured that dextrose gel used for prophylaxis or treatment of neonatal hypoglycaemia does not alter the neonatal gut microbiome. TRIAL REGISTRATION NUMBER 12614001263684.
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Affiliation(s)
- Sophie L St Clair
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Jane E Harding
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | | | - Gregory D Gamble
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Jane M Alsweiler
- Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand
- Newborn Services, Auckland City Hospital, Auckland, New Zealand
| | - Tommi Vatanen
- Liggins Institute, The University of Auckland, Auckland, New Zealand
- The Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
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22
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Desai P, Verma S, Bhargava S, Rice M, Tracy J, Bradshaw C. Implementation and outcomes of a standard dose dextrose gel protocol for management of transient neonatal hypoglycemia. J Perinatol 2022; 42:1097-1102. [PMID: 34975147 DOI: 10.1038/s41372-021-01284-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/06/2021] [Accepted: 11/23/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE The use of oral dextrose gel (DG) reduces IV dextrose use. Prior studies used weight-based dosing (WD), though barriers exist, and are mitigated using standard dosing (SD). Our outcomes include IV dextrose use, NICU admissions, breastfeeding, adverse events, and assessment of WD vs SD. STUDY DESIGN Retrospective chart review comparing pre-DG, WD, and SD in 16490 newborns (1329 hypoglycemic) ≥ 35 weeks admitted to the nursery over 3 years. RESULTS There was reduction in IV dextrose use 10.9% vs 6.5% (p = 0.004) and NICU admissions 27.9% vs 16.1% (p < 0.001) associated with DG use, and increased rate of breastfed infants 33.8% vs 43.5% (p = 0.001), with no difference between WD and SD. No difference noted in adverse events across the study period. CONCLUSIONS DG utilization is associated with reduced IV dextrose use, NICU admissions, and improved breastfeeding rates without changes in adverse events. We offer SD as a safe alternative to WD.
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Affiliation(s)
- Purnahamsi Desai
- New York University Grossman School of Medicine, New York, NY, USA. .,New York University Langone Health Center, New York, NY, USA.
| | - Sourabh Verma
- New York University Grossman School of Medicine, New York, NY, USA.,New York University Langone Health Center, New York, NY, USA
| | - Sweta Bhargava
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Marissa Rice
- SUNY Upstate Medical University, Syracuse, NY, USA
| | - Joanna Tracy
- New York University Langone Health Center, New York, NY, USA
| | - Chanda Bradshaw
- New York University Grossman School of Medicine, New York, NY, USA.,New York University Langone Health Center, New York, NY, USA
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23
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Harding JE, Rajay AB, Alsweiler JM, Brown G, Crowther CA, Franke N, Gamble G, McKinlay C, Milne B, Rogers J, Wouldes T. Different Approaches to requesting Consent for Routine data linkage in Neonatal follow-up (ACORN): protocol for a 2×2 factorial randomised trial. BMJ Open 2022; 12:e060476. [PMID: 35831046 PMCID: PMC9280877 DOI: 10.1136/bmjopen-2021-060476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Routinely collected data can be linked to research data to create a rich dataset and inform practice. However, consent is normally required to link identifiable data. Reported rates of consent to data linkage for children ranged from 21% to 96%, but no studies have investigated different approaches to seeking consent for data linkage for school-age children. METHODS AND ANALYSIS The Approaches to Consent for Routine Data Linkage in Neonatal Follow-up (ACORN) trial is a 2×2 factorial randomised trial to assess whether, for children who participated in neonatal randomised trials (pre-hypoglycaemia Prevention with Oral Dextrose Gel (hPOD), hPOD and The Impact of Protein Intravenous Nutrition on Development in Extremely Low Birth Weight Babies (ProVIDe)) and are approached to participate in an in-person assessment at 6-7 years of age, parental consent to data linkage is higher if consent is sought (1) after the in-person assessment (delayed) or concurrently and (2) for health and education data combined or separately. The primary outcomes will be rates of consent to linkage of (1) either health or education data and (2) both health and education data. A pilot study indicates the potentially available cohort size of 2110 (80% follow-up of the neonatal trial cohorts) would be adequate to detect an absolute difference of 6%-5%-4% from a baseline consent rate of 70%-85%-90%, respectively (2-tailed alpha 0.05, 90% power). With at least 1136 participants, the ACORN trial would have 90% power to detect an absolute difference of 5% in the primary outcome for each factor, assuming a consent rate of 90% in the control groups and alpha 0.05. Data are categorical and will be presented as number and per cent. The effects of factors will be tested using generalised linear models and presented as ORs and 95% CIs. ETHICS AND DISSEMINATION Ethics approval by the New Zealand Health and Disability Ethics Committee (19/STH/202). Dissemination will be via peer-reviewed publications, scientific meetings, educational sessions and public fora. TRIAL REGISTRATION NUMBER ACTRN12621000571875 (Australian New Zealand Clinical Trials Registry).
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Affiliation(s)
- Jane E Harding
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | | | - Jane Marie Alsweiler
- Department of Paediatrics Child and Youth Health, The University of Auckland, Auckland, New Zealand
| | - Gavin Brown
- Faculty of Education and Social Work, The University of Auckland, Auckland, New Zealand
| | | | - Nike Franke
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Greg Gamble
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Christopher McKinlay
- Liggins Institute, The University of Auckland, Auckland, New Zealand
- Department of Paediatrics Child and Youth Health, The University of Auckland, Auckland, New Zealand
| | - Barry Milne
- Centre of Methods and Policy Application in the Social Sciences, The University of Auckland, Auckland, New Zealand
| | - Jenny Rogers
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Trecia Wouldes
- Department of Psychological Medicine, The University of Auckland, Auckland, New Zealand
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24
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Gupta K, Amboiram P, Balakrishnan U, C A, Abiramalatha T, Devi U. Dextrose Gel for Neonates at Risk With Asymptomatic Hypoglycemia: A Randomized Clinical Trial. Pediatrics 2022; 149:188021. [PMID: 35582897 DOI: 10.1542/peds.2021-050733] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/15/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Hypoglycemia occurs in 5% to 15% of neonates in the first few days. A significant proportion requires admission for intravenous fluids. Dextrose gel may reduce admissions and mother-infant separation. We aimed to study the utility of dextrose gel in reducing the need for intravenous fluids. METHODS This stratified randomized control trial included at-risk infants with asymptomatic hypoglycemia. Study populations were stratified into 3 categories: small for gestational age (SGA) and intrauterine growth-restriction (IUGR), infants of diabetic mothers (IDM) and large for gestational age (LGA), and late preterm (LPT) neonates. Intervention group received dextrose gel followed by breastfeeding, and the control group (CG) received only breastfeeding. RESULTS Among 629 at-risk infants, 291 (46%) developed asymptomatic hypoglycemia; 147 (50.4%) in the dextrose gel group (DGG) and 144 (49.6%) in CG. There were 97, 98, and 96 infants in SGA/IUGR, IDM/LGA, and LPT categories, respectively. Treatment failure in the DGG was 17 (11.5%) compared to 58 (40.2%) in CG, with a risk ratio of 0.28 (95% confidence interval [CI]: 0.17-0.46; P < .001). Treatment failure was significantly less in DGG in all 3 categories: SGA/IUGR, IDM/LGA, and LPT with a risk ratio of 0.29 (95% CI:0.13-0.67), 0.31 (95% CI:0.14-0.66) and 0.24 (95% CI:0.09-0.66), respectively. CONCLUSIONS Dextrose gel reduces the need for intravenous fluids in at-risk neonates with asymptomatic hypoglycemia in the first 48 hours of life.
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25
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Carr CP, MacMillan H, Reynolds PR. Routine buccal glucose reduces admission hypoglycaemia in premature newborns: A quality improvement project. Acta Paediatr 2022; 111:1709-1711. [PMID: 35604040 DOI: 10.1111/apa.16419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/08/2022] [Accepted: 05/20/2022] [Indexed: 11/29/2022]
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26
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Rajay AB, Harding JE. Variations in New Zealand and Australian guidelines for the management of neonatal hypoglycaemia: A secondary analysis from the hypoglycaemia Prevention with Oral Dextrose gel Trial (hPOD). J Paediatr Child Health 2022; 58:820-829. [PMID: 34866258 DOI: 10.1111/jpc.15846] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 05/17/2021] [Accepted: 11/24/2021] [Indexed: 11/30/2022]
Abstract
AIM We observed wide variation in the management of babies at risk of hypoglycaemia who participated in the hPOD (hypoglycaemia Prevention with Oral Dextrose gel) multicentre trial of prophylactic dextrose gel. The aim of this study was to identify whether this may be due to variations in the clinical guidelines used by participating hospitals. METHODS Guidelines for management of neonatal hypoglycaemia used by participating hospitals were reviewed. Recommendations regarding definition, risk factors, monitoring and treatment were compared between countries, hospital type (tertiary or secondary) and neonatal intensive care unit size (≤12 cots and >12 cots). RESULTS The 18 hospitals used 20 guidelines. The recommended diagnostic threshold for hypoglycaemia ranged from <2.0 mmol/L to <2.6 mmol/L, and glucose oxidase method of testing was recommended in seven (47%) of 15 guidelines. There was broad agreement about which infants should be monitored. Oral dextrose was the recommended first line of treatment in 17 of 20 guidelines, but the glucose threshold at which this should be used varied (≤2.6 mmol/L in New Zealand, 1.5-2.6 mmol/L in Australia). Re-checking blood glucose concentrations after oral dextrose was recommended at 30 min in most (10/11, 91%) New Zealand guidelines but at 60 min in most (4/6, 67%) Australian guidelines. There was greatest variation in recommended thresholds for referral to paediatric services or neonatal intensive care unit, and administration of intravenous dextrose. There were no significant differences between guidelines used by tertiary and secondary hospitals, or large and small hospitals. CONCLUSION There is wide variation in guideline recommendations for the management of neonatal hypoglycaemia across New Zealand and Australian neonatal units.
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Affiliation(s)
- Aakash B Rajay
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Jane E Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand
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27
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Affiliation(s)
- Paul J Rozance
- Perinatal Research Center, University of Colorado, School of Medicine, Aurora
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28
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Edwards T, Alsweiler JM, Crowther CA, Edlin R, Gamble GD, Hegarty JE, Lin L, McKinlay CJD, Rogers JA, Thompson B, Wouldes TA, Harding JE. Prophylactic Oral Dextrose Gel and Neurosensory Impairment at 2-Year Follow-up of Participants in the hPOD Randomized Trial. JAMA 2022; 327:1149-1157. [PMID: 35315885 PMCID: PMC8941358 DOI: 10.1001/jama.2022.2363] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 02/07/2022] [Indexed: 01/24/2023]
Abstract
Importance Prophylactic oral dextrose gel reduces neonatal hypoglycemia, but later benefits or harms remain unclear. Objective To assess the effects on later development of prophylactic dextrose gel for infants born at risk of neonatal hypoglycemia. Design, Setting, and Participants Prospective follow-up of a multicenter randomized clinical trial conducted in 18 Australian and New Zealand hospitals from January 2015 to May 2019. Participants were late preterm or term at-risk infants; those randomized in 9 New Zealand centers (n = 1359) were included and followed up between January 2017 and July 2021. Interventions Infants were randomized to prophylactic 40% dextrose (n = 681) or placebo (n = 678) gel, 0.5 mL/kg, massaged into the buccal mucosa 1 hour after birth. Main Outcomes and Measures The primary outcome of this follow-up study was neurosensory impairment at 2 years' corrected age. There were 44 secondary outcomes, including cognitive, language, and motor composite Bayley-III scores (mean [SD], 100 [15]; higher scores indicate better performance). Results Of eligible infants, 1197 (91%) were assessed (581 females [49%]). Neurosensory impairment was not significantly different between the dextrose and placebo gel groups (20.8% vs 18.7%; unadjusted risk difference [RD], 2.09% [95% CI, -2.43% to 6.60%]; adjusted risk ratio [aRR], 1.13 [95% CI, 0.90 to 1.41]). The risk of cognitive and language delay was not significantly different between the dextrose and placebo groups (cognitive: 7.6% vs 5.3%; RD, 2.32% [95% CI, -0.46% to 5.11%]; aRR, 1.40 [95% CI, 0.91 to 2.17]; language: 17.0% vs 14.7%; RD, 2.35% [95% CI, -1.80% to 6.50%]; aRR, 1.19 [95% CI, 0.92 to 1.54]). However, the dextrose gel group had a significantly higher risk of motor delay (2.5% vs 0.7%; RD, 1.81% [95% CI, 0.40% to 3.23%]; aRR, 3.79 [95% CI, 1.27 to 11.32]) and significantly lower composite scores for cognitive (adjusted mean difference [aMD], -1.30 [95% CI, -2.55 to -0.05]), language (aMD, -2.16 [95% CI, -3.86 to -0.46]), and motor (aMD, -1.40 [95% CI, -2.60 to -0.20]) performance. There were no significant differences between groups in the other 27 secondary outcomes. Conclusions and Relevance Among late preterm and term infants born at risk of neonatal hypoglycemia, prophylactic oral 40% dextrose gel at 1 hour of age, compared with placebo, resulted in no significant difference in the risk of neurosensory impairment at 2 years' corrected age. However, the study may have been underpowered to detect a small but potentially clinically important increase in risk, and further research including longer-term follow-up is required. Trial Registration anzctr.org.au Identifier: ACTRN12614001263684.
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Affiliation(s)
- Taygen Edwards
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Jane M. Alsweiler
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
- Newborn Services, Auckland City Hospital, Auckland, New Zealand
| | | | - Richard Edlin
- Health Systems, School of Population Health, University of Auckland, Auckland, New Zealand
| | - Greg D. Gamble
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | | | - Luling Lin
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Christopher J. D. McKinlay
- Liggins Institute, University of Auckland, Auckland, New Zealand
- Kidz First Neonatal Care, Counties Manukau Health, Auckland, New Zealand
| | - Jenny A. Rogers
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Benjamin Thompson
- School of Optometry and Vision Science, Waterloo, Ontario, Canada
- Center for Eye and Vision Research, Hong Kong
| | - Trecia A. Wouldes
- Department of Psychological Medicine, University of Auckland, Auckland, New Zealand
| | - Jane E. Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand
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29
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Hegarty JE, Alsweiler JM, Gamble GG, Crowther CA, Harding JE. Effect of Prophylactic Dextrose Gel on Continuous Measures of Neonatal Glycemia: Secondary Analysis of the Pre-hPOD Trial. J Pediatr 2021; 235:107-115.e4. [PMID: 33798509 PMCID: PMC8502486 DOI: 10.1016/j.jpeds.2021.03.057] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 03/25/2021] [Accepted: 03/26/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To determine the effects of different doses of prophylactic dextrose gel on glycemic stability assessed using continuous glucose monitoring in the first 48 hours when given to babies at risk of neonatal hypoglycemia. STUDY DESIGN Continuous glucose monitoring was undertaken for the first 48 hours in 133 infants at risk of hypoglycemia who participated in the pre-hPOD randomized dosage trial of dextrose gel prophylaxis. RESULTS Low glucose concentrations were detected in 41% of infants by blood glucose monitoring and 68% by continuous interstitial glucose monitoring. The mean ± SD duration of low interstitial glucose concentrations was 295 ± 351 minutes in the first 48 hours. Infants who received any dose of dextrose gel seemed to be less likely than those who received placebo gel to experience low glucose concentrations (<47 mg/dL [2.6 mmol/L]; P = .08), particularly if they received a single dose of 200 mg/kg (relative risk, 0.70; 95% CI, 0.50-0.10; P = .049). They also spent a greater proportion of time in the central glucose concentration range of 54-72 mg/dL (3-4 mmol/L) (any dose, mean ± SD, 58.2 ± 20.3%; placebo, 50.0 ± 21.9%; mean difference, 8.20%; 95% CI, 0.43-15.9%; P = .038). Dextrose gel did not increase recurrent or severe episodes of low glucose concentrations and did not increase the peak glucose concentration. These effects were similar for all trial dosages. CONCLUSIONS Low glucose concentrations were common in infants at risk of hypoglycemia despite blood glucose monitoring and treatment. Prophylactic dextrose gel reduced the risk of hypoglycemia without adverse effects on glucose stability.
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Affiliation(s)
- Joanne E Hegarty
- Liggins Institute, University of Auckland, New Zealand,Newborn Services, Auckland City Hospital, Auckland, New Zealand
| | - Jane M Alsweiler
- Newborn Services, Auckland City Hospital, Auckland, New Zealand,Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | | | | | - Jane E Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand.
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30
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Liu GX, Grigg CP, Harding JE. New Zealand Practitioners' Views About Neonatal Hypoglycaemia and Its Management. J Paediatr Child Health 2021; 57:1150-1152. [PMID: 33963653 DOI: 10.1111/jpc.15545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/21/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Gordon Xh Liu
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Celia P Grigg
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Jane E Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand
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31
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Alsweiler JM, Harris DL, Harding JE, McKinlay CJD. Strategies to improve neurodevelopmental outcomes in babies at risk of neonatal hypoglycaemia. THE LANCET. CHILD & ADOLESCENT HEALTH 2021; 5:513-523. [PMID: 33836151 PMCID: PMC8528170 DOI: 10.1016/s2352-4642(20)30387-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 11/26/2020] [Accepted: 12/04/2020] [Indexed: 10/21/2022]
Abstract
Neonatal hypoglycaemia is associated with adverse development, particularly visual-motor and executive function impairment, in childhood. As neonatal hypoglycaemia is common and frequently asymptomatic in at-risk babies-ie, those born preterm, small or large for gestational age, or to mothers with diabetes, it is recommended that these babies are screened for hypoglycaemia in the first 1-2 days after birth with frequent blood glucose measurements. Neonatal hypoglycaemia can be prevented and treated with buccal dextrose gel, and it is also common to treat babies with hypoglycaemia with infant formula and intravenous dextrose. However, it is uncertain if screening, prophylaxis, or treatment improves long-term outcomes of babies at risk of neonatal hypoglycaemia. This narrative review assesses the latest evidence for screening, prophylaxis, and treatment of neonates at risk of hypoglycaemia to improve long-term neurodevelopmental outcomes.
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Affiliation(s)
- Jane M Alsweiler
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand.
| | - Deborah L Harris
- School of Nursing Midwifery and Health Practice, Victoria University of Wellington, Wellington, New Zealand
| | - Jane E Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand
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32
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Edwards T, Liu G, Hegarty JE, Crowther CA, Alsweiler J, Harding JE. Oral dextrose gel to prevent hypoglycaemia in at-risk neonates. Cochrane Database Syst Rev 2021; 5:CD012152. [PMID: 33998668 PMCID: PMC8127543 DOI: 10.1002/14651858.cd012152.pub3] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Neonatal hypoglycaemia is a common condition that can be associated with brain injury. Current practice usually includes early identification of at-risk infants (e.g. infants of diabetic mothers; preterm, small- or large-for-gestational-age infants), and prophylactic measures are advised. However, these measures usually involve use of formula milk or admission to the neonatal unit. Dextrose gel is non-invasive, inexpensive and effective for treatment of neonatal hypoglycaemia. Prophylactic dextrose gel can reduce the incidence of neonatal hypoglycaemia, thus potentially reducing separation of mother and baby and supporting breastfeeding, as well as preventing brain injury. This is an update of a previous Cochrane Review published in 2017. OBJECTIVES: To assess the effectiveness and safety of oral dextrose gel given to newborn infants at risk of hypoglycaemia in preventing hypoglycaemia and reducing long-term neurodevelopmental impairment. SEARCH METHODS We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2020, Issue 10) in the Cochrane Library; and Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Daily and Versions(R) on 19 October 2020. We also searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs comparing oral dextrose gel versus placebo, no intervention, or other therapies for the prevention of neonatal hypoglycaemia. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed risk of bias. We contacted investigators to obtain additional information. We used fixed-effect meta-analyses. We used the GRADE approach to assess the certainty of evidence. MAIN RESULTS We included two studies conducted in high-income countries comparing oral dextrose gel versus placebo in 2548 infants at risk of neonatal hypoglycaemia. Of these, one study was included in the previous version of this review. We judged these two studies to be at low risk of bias, and that the evidence for most outcomes was of moderate certainty. Meta-analysis of the two studies showed that oral dextrose gel reduces the risk of hypoglycaemia (risk ratio (RR) 0.87, 95% confidence interval (CI) 0.79 to 0.95; risk difference (RD) -0.06, 95% CI -0.10 to -0.02; 2548 infants; high certainty evidence). One study reported that oral dextrose gel probably reduces the risk of major neurological disability at two years' corrected age (RR 0.21, 95% CI 0.05 to 0.78; RD -0.05, 95% CI -0.09 to 0.00; 360 infants; moderate certainty evidence). Meta-analysis of the two studies showed that oral dextrose gel probably reduces the risk of receipt of treatment for hypoglycaemia during initial hospital stay (RR 0.89, 95% CI 0.79 to 1.00; 2548 infants; moderate certainty evidence) but makes little or no difference to the risk of receipt of intravenous treatment for hypoglycaemia (RR 1.01, 0.68 to 1.49; 2548 infants; moderate certainty evidence). Oral dextrose gel may have little or no effect on the risk of separation from the mother for treatment of hypoglycaemia (RR 1.12, 95% CI 0.81 to 1.55; two studies, 2548 infants; low certainty evidence). There is probably little or no difference in the risk of adverse events in infants who receive oral dextrose gel compared to placebo gel (RR 1.22, 95% CI 0.64 to 2.33; two studies, 2510 infants; moderate certainty evidence), but there are no studies comparing oral dextrose with other comparators such as no treatment, standard care or other therapies. No data were available on exclusive breastfeeding after discharge. AUTHORS' CONCLUSIONS Oral dextrose gel reduces the risk of neonatal hypoglycaemia in at-risk infants and probably reduces the risk of major neurological disability at two years of age or greater without increasing the risk of adverse events compared to placebo gel. Additional large follow-up studies at two years of age or older are required. Future research should also be undertaken in low- and middle-income countries, preterm infants, using other dextrose gel preparations, and using comparators other than placebo gel. There are three studies awaiting classification and one ongoing study which may alter the conclusions of the review when published.
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Affiliation(s)
- Taygen Edwards
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Gordon Liu
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Joanne E Hegarty
- Liggins Institute, University of Auckland, Auckland, New Zealand
- Neonatal Intensive Care Unit, Auckland Hospital, Auckland, New Zealand
| | - Caroline A Crowther
- Liggins Institute, University of Auckland, Auckland, New Zealand
- ARCH: Australian Research Centre for Health of Women and Babies, Robinson Research Institute, Discipline of Obstetrics and Gynaecology, The University of Adelaide, Adelaide, Australia
| | - Jane Alsweiler
- Neonatal Intensive Care Unit, Auckland Hospital, Auckland, New Zealand
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Jane E Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand
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